Inspection on 06/09/07 for Spetisbury Manor

This inspection was carried out on 6th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Spetisbury Manor 15/12/06

Spetisbury Manor 22/05/06

Spetisbury Manor 17/03/06

Spetisbury Manor 13/06/05

Spetisbury Manor 26/11/04

Spetisbury Manor 13/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Spetisbury Manor Spetisbury Blandford Dorset DT11 9EB Lead Inspector Catherine Churches Key Unannounced Inspection 6th September 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spetisbury Manor Address Spetisbury Blandford Dorset DT11 9EB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01258 857378 01258 858384 Country House Care Limited Mrs Sally Scott Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of four bedrooms from those listed may be used for shared occupancy at any one time: Rooms 2, 3, 6, 16, Kingfisher, Mallard and Heron Suites. One named person (as known to CSCI) in the category of PD may be accommodated to receive care. 15th December 2006 Date of last inspection Brief Description of the Service: Spetisbury Manor is registered to provide personal care for a maximum of 25 older people in 21 rooms, 4 of which may be used as shared rooms by residents who have made a positive choice to share with each other. Mr Kevin Ellis is the Responsible Individual; he also owns another registered care home, Glenhurst Manor in Bournemouth. The Registered Manager is Mrs Sally Scott. The home is situated on the outskirts of the small village of Spetisbury. Some residents frequently travel in the homes courtesy car to go shopping in Blandford, Wimborne and Poole. Spetisbury Manor stands in four acres of grounds laid to attractive gardens leading down to the river Stour. The accommodation is on three floors with a passenger lift serving the first and second floors. Eighteen bedrooms have en-suite bathroom facilities, and there are assisted bathrooms and toilets on each floor. At the time of the inspection the current scale of charges per week ranged from £450 to £1200 (for a double room double occupancy). Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on 6th September 2007. In total five hours were spent in the home undertaking the inspection. Mrs Scott, the registered manager was present throughout the inspection. The inspection took place as part of the regular, programmed inspection schedule for the home. The last inspection was December 2006. The purpose of this visit was to monitor the homes compliance with National Minimum Standards and with recommendations made during the previous inspection. Also, to check that the home is run in a satisfactory manner and that the people who are living in the home are properly cared for. The premises were inspected and a number of records examined. Time was also spent time observing routines within the home and talking with residents, visitors and staff. Without exception, the feedback received from residents, visitors and visiting health professionals was positive. Some of the following quotes were received during the visit: “They (the staff) are sensitive and caring to my needs” “I’m never lonely and the staff are very kind” “The meals are first class” “The staff are excellent and have a sense of humour” What the service does well: Spetisbury Manor provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home is well presented, clean and warm. The home also has extensive, well-maintained grounds including access to the river Stour which runs through the garden. Some residents have even been able to take advantage of the fishing rights with the assistance of the home’s handyman. Good care is provided from a strong and well trained group of staff. Medication is well managed at the home to promote health and well-being. Residents say that staff are kind and caring and that their privacy and dignity is respected at all times. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 6 All residents, and visitors, spoken with were positive about the care and attention they receive. There is a good range of activities in the home and visitors are encouraged to come to the home whenever possible. Residents are encouraged to maintain their links with family and friends and visitors to Spetisbury Manor are made welcome. People are positive about the food at Spetisbury Manor. Food is well presented and staff are available to assist residents if help is required. The Complaints and Adult Protection procedures ensure residents and their representatives that their well-being and comfort is important to the home and that any concerns raised will be properly investigated and resolved. The staff group is stable and were observed to be respectful, caring and helpful. Sufficient numbers of staff are on duty throughout the day and night to be able to meet the care needs of the residents. The manager is very capable and has created an implemented a successful improvement plan for the home. Financial procedures within the home ensure that resident’s interests are protected. What has improved since the last inspection? Pre-admission assessments have improved which means that staff are better prepared to meet residents needs. The care planning system has improved thereby creating a better monitoring care needs and a more proactive service for residents. Nutritional screening is now being undertaken providing further information for staff about resident’s healthcare needs. The laundry area has been refurbished and extended and has also been equipped with better specification equipment. This means that infection control methods in the home as well as staff working conditions have improved together with an improved service for residents. A programme for covering radiators has been implemented and those identified as the highest risk have been addressed. The programme is not yet complete. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory pre admission procedure is now in place. Assessments are undertaken and this means that the home tries to ensure that only those residents whose needs can be met by the home are offered places at Spetisbury Manor. EVIDENCE: The files of two residents who had been recently admitted to the home were reviewed. Assessments had improved since the last inspection as the documentation has been expanded : ethnicity is actively discussed and a checklist has been developed to ensure all the required areas are addressed. Evidence was available that the resident and/or their representative had been involved. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 10 Assessments are now being carried out on people returning to the home from hospital or for additional respite visits. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system has been further improved. Each individual has a detailed, person centred plan of care and residents are involved in its development and review. The care plan provides good evidence of the care that is being delivered. The health needs of residents are actively promoted with good consultation and communication with local health services. EVIDENCE: The care documentation for three residents was reviewed. Each file contained up to date risk assessments, care plans, daily records and reviews. Care plans covered all areas required under the National Minimum Standards and were individual, person centred documents that were up to date and informative. The quality of the entries by staff in records has improved following a training session developed by the manager. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 12 Reviews were being undertaken at the required intervals and changes in need were reflected in an updated care plan. Nutritional screening has been introduced since the last inspection. Evidence was available that the resident and/or family member had been involved in the creation of the care plan. Residents confirmed that they have access to medical services. Records are kept of visits from GP’s, district nurses, chiropodist, optician and dentist. The home has a satisfactory medication policy and procedure. Medicines are stored securely and only those staff that have undertaken appropriate training in medicines administration are authorised to give medicines to the residents. Records were kept of the receipt, administration and disposal of medicines. Examination of records indicated that medicines are properly administered in accordance with the prescriber’s instructions. All residents spoken with said that their privacy is respected and that they were treated with dignity. Staff were seen to knock at bedroom doors and treated residents with courtesy and kindness. All residents seen were well presented. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Spetisbury Manor provides a caring, homely and relaxed environment. The range of recreational activities available in the home as well as trips out has been further improved and is excellent. Open visiting arrangements are in place enabling residents to retain contact with families and friends. Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. Dietary needs of the residents are very well catered for with a huge variety of choices as well as balanced and varied menus which meet resident’s tastes and needs. EVIDENCE: Mrs Scott and the staff understand the importance of activity and fulfilment for residents. To this end there are frequent trips out in small groups or on a one Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 14 to one basis, various organised activities such as quizzes and exercises and visiting entertainers. Residents are also encouraged to continue any interests that they followed prior to moving to the home. The handyman had even come to the home in his own time to take residents fishing. The visitor’s book showed that there is a constant stream of visitors to the home and discussions with staff confirmed this as well as the fact that many residents are taken out by visitors. During the course of the inspection visitors were observed in the home. They were made welcome by staff and clearly had a good relationship with the staff. Discussion with residents and staff as well as examination of records and observation during the inspection evidenced that residents are assisted appropriately to exercise choice and control over their lives. Residents and staff confirmed that, in their opinion, a suitable and varied diet is provided in the home. Foods records were examined and confirmed this to be the case. Residents said they enjoyed their food. One person commented “the food is excellent”, the staff had comprehensive lists of likes and dislikes and a wide range of meals are prepared to suit all tastes and appetites. Stocks were plentiful and of very good quality. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Spetisbury Manor has a satisfactory policy and procedure for the making of complaints. This means that residents and others involved in the home that may wish to make a complaint should feel confident that they would be listened to and matters of concern will be acted upon. Arrangements for protecting service users from abuse were satisfactory. This means that Spetisbury Manor is a safe environment that will protect residents from abuse. EVIDENCE: Spetisbury Manor has a satisfactory complaints procedure that is displayed in the home as well as included in the Service Users Guide. Those spoken to confirmed that they knew how to make complaints and would feel able to do so should the need arise. Two complaints had been made to the home since the last inspection. These had been investigated and appropriately documented. No complaints have been made to CSCI. Policies and procedures for adult protection and whistle blowing were checked and found to be satisfactory. Staff have also received training in the signs and symptoms of abuse and action they should take should they suspect abuse is taking place. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 16 Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is very well presented: it is nicely decorated and furnished and has a homely atmosphere. The grounds are also very well maintained, providing lots of colour and interest as well as a variety of places to sit and relax. The home maintains a good standard of hygiene and all areas seen were clean and free from offensive odours. EVIDENCE: Residents at the home enjoy the delightful surroundings of the Manor and its well-maintained gardens. All rooms have a unique character, and are furnished to a high standard. Matching soft furnishings complement each room, which are refurbished as they become vacant. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 18 A number of residents were spoken with in the privacy of their own rooms. All were very happy with the environment, commenting on how they had been assisted to bring furniture with them, the dedication of the cleaning staff and the pleasure that the beautiful surroundings gives them. The manager outlined plans to refurbish the home’s dining room and create an Orangery. Some radiators in the home remain uncovered. The manager confirmed that highest risk radiators have already been covered and that a programme is in place to cover those still outstanding. All areas of the home visited were clean, hygienic and free from offensive odours. Since the last inspection the laundry area has been extended and refurbished and now provides a much better environment for staff in which it is easier to care for residents belongings and implement infection control procedures. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff working in the home meets residents’ needs. The home has identified staff training needs and implemented a training programme to address areas of weakness. The home has a good ratio of care staff who have achieved National Vocational Qualifications and has introduced the Skills for Care Induction training; thus working to ensure that residents are in safe hands at all times. People living at Spetisbury Manor are satisfactorily supported and protected by the home’s recruitment policy and practices. EVIDENCE: Examination of the staff rota and observation throughout the inspection demonstrated there was a sufficient number and skill mix of staff to meet the needs of residents. All residents spoken with confirmed that staff were always available, kind and helpful. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 20 At the time of the visit six staff members held a National Vocational Qualification of the ten care staff working in the home. A further member of staff has started an NVQ programme at level 2. Three staff files were seen. The files contained items as required by legislation. The manager has completed an analysis of staff training needs and has implemented a training plan, which includes mandatory subjects, to address these. The new Skills for Care induction programme has been implemented in the home. The manager reported some difficulties in meeting the timescales for some staff. These reasons were unavoidable and the manager was advised to document them. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Scott holds appropriate management qualifications as well as having many years experience in nursing. She is a competent, approachable and committed manager. This results in a home where residents, staff and visitors feel supported and consulted and visible improvements are being made to the service. The management arrangements for the home support good care practice for the residents. Quality monitoring systems have been improved and this provides further evidence that the home is run in the best interests of the residents. Resident’s finances are safeguarded with clear policies and procedures and management guidance. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 22 The health, safety and welfare of residents and staff is protected by the systems that the home has in place for staff training, maintenance and risk assessment. EVIDENCE: The management arrangements for the home support good care practices for the residents. Mrs Scott has demonstrated that she is a competent manager both through training and experience as well as the improvements that continue to be evidenced at each inspection. Systems for quality assurance and resident consultation have been developed with the aim of ensuring that the home is run in the best interests of the residents and that performance issues are identified and addressed. Mrs Scott confirmed that residents are encouraged to retain control of their own finances for as long as possible. Where they state that they no longer wish to or they lack the capacity to do so then the home ensures that either family or other representatives such as solicitors take on this role. No cash or valuables are held in the home for residents. Fire records, staff training records and accident books were examined and found to be up to date and detailed. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 3. Refer to Standard OP25 Good Practice Recommendations All pipework and radiators should be guarded or have guaranteed low surface temperatures. Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Spetisbury Manor DS0000026768.V350430.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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